Governments Need to Ensure That MAID Safeguards Don’t Harm Individuals

Public debate about medical assistance in dying (MAID) in Canada has centred on eligibility and safeguards. The focus is often on where to draw the line — who should qualify, and under what conditions.

Less attention has been paid to an equally important question: how do the rules shape the decisions people make in real life?

As the Alberta government moves ahead this month with legislation that could limit access, it — like all governments — should carefully consider the impact of its changes.

Policy discussions tend to frame the issue in one of two ways. Either access is too broad and needs tightening or safeguards must be strengthened to protect vulnerable people.

But that framing misses something important. Safeguards don’t operate in isolation. They influence how people understand their options, how they time decisions and whether they can access care within a regulated system at all.

A common assumption is that restricting eligibility reduces risk of premature access or errors in assessing cases. But for people living with persistent, intolerable suffering, removing access to a structured pathway does not remove the suffering itself. It changes the context in which decisions are made.

When access is constrained, people are not left with no options. They are left with fewer supported ones. Decisions may move from formal medical systems — without the same assessment, oversight, or continuity of care. In that sense, risk is not eliminated. It is displaced from a system with legal and medical checks and balances to an informal one.

This dynamic is especially visible among patients whose deaths are not considered reasonably foreseeable. These so-called Track 2 patients face stricter safeguards, including a longer assessment period, multiple independent evaluations and requirements to ensure treatment options have been carefully considered. They’re often described as a single category, but the group includes people with severe, long-standing conditions that have not responded to treatment, as well as conditions that are difficult to predict over time.

When policy relies on rigid timelines — such as a requirement that death be foreseeable within a certain period — it redefines eligibility and the way we think about MAID. The focus shifts away from the experience of suffering and toward how confidently a trajectory can be predicted.

In practice, that creates a tension. People whose suffering is significant may still be excluded, not because their condition is less serious, but because it does not fit within a defined timeframe. The result is not simply a denial of access. It can change how and when decisions are made.

When access depends on meeting specific criteria within a particular window, some people may feel pressure to act earlier than they otherwise would. This is often discussed in the context of conditions such as dementia. Where advance requests remain uncertain or unavailable, individuals may conclude that their only opportunity to make a decision lies before they lose capacity.

That can move decision-making into earlier, more uncertain stages of illness — not because people prefer it that way, but because policy leaves little room for anything else. More broadly, these frameworks do more than regulate access. They shape what counts as acceptable suffering within the system.

By drawing lines based on prognosis or timing, policy risks shifting away from individual assessment and toward categorical exclusion. Suffering that does not fit neatly within those categories does not disappear. It becomes harder to recognize within the system.

The language of protecting the vulnerable plays an important role in these discussions, and for good reason. Protection matters. But vulnerability is not a single, fixed state. People differ in their capacity, their insight and the persistence of their suffering.

That concern is often framed in terms of socioeconomic vulnerability, lack of supports or disability. But national data offers a more complex picture. Health Canada’s most recent annual report on MAID found that recipients do not disproportionately come from lower-income communities, and that the majority had access to palliative care or other support services.

While disability is more common among patients whose deaths are not reasonably foreseeable, they still represent a small proportion of overall cases. These findings do not eliminate concern, but they do suggest that the relationship between vulnerability and MAID is more nuanced than it is often presented.

When policies treat vulnerability as uniform, they can blur the distinction between needing protection and being capable of an informed choice.

In doing so, they risk overriding the autonomy of people who retain decision-making capacity but fall outside defined criteria.

There is also a tendency to assume that those who are barred from MAID due to eligibility thresholds are uncertain or unsupported in making their own decisions.

In reality, many have undergone extensive treatment, have reflected on their situation over time and are seeking options within a regulated system precisely because they want their decisions to be assessed and supported.

When those pathways narrow, the effects are not always visible, but they are real.

People may face decisions that are more time-pressured, less supported and more difficult to navigate. What was intended as a safeguard can begin to reshape behaviour in ways that are harder to anticipate.

None of this argues against safeguards themselves. Careful assessment, evaluation of capacity and attention to treatment history are all essential.

But safeguards do not exist in the abstract. They operate within systems, and those systems shape how people respond.

When safeguards become overly rigid or broadly exclusionary, they can begin to work against their intended purpose.

A more balanced approach would focus less on categorical thresholds and more on how safeguards function in practice. That means recognizing the role of time in decision-making, the diversity of patient experiences and the importance of maintaining access to structured, regulated pathways.

The current debate has focused largely on who should qualify for MAID. An equally important question is how the system influences the choices people make along the way. If policy shifts decisions earlier, or pushes them outside supported systems, then it begins to reshape the landscape of care itself.

At that point, the question is no longer only about access. It is about whether the system is supporting people in making considered decisions — or quietly narrowing the conditions under which those decisions can happen.